The government likes to give the impression it is listening and consulting. But when it comes to abolishing community health councils the people's voice has fallen on deaf ears, says Peter Walsh
One of the welcome thrusts of the new NHS has been the commitment to evidencebased decision-making. The NHS plan was preceded by one of the biggest, and most expensive, listening exercises ever to gather the views of the public and staff about the future of the NHS.
1The public and staff were encouraged to fill in and return slips about their priorities. A number of working parties - modernisation action teams - were set up with representation that included national voluntary groups and a range of professions.
And the College of Health was commissioned to run meetings and interview stakeholders.
As we now know, the shock announcement in the plan to abolish community health councils has proved to be its most controversial aspect. Surely the rationale for this could be traced back to evidence gathered as part of the listening exercise, as ministers implied during debates in the House of Commons?
What happened to all those little slips that we filled in and sent off? Appendix 1 of the NHS plan summarises what were said to be the public's main concerns, and there is nothing there to suggest a radical shift in the way the public wants to be involved and represented.
Nor is there in the report from the College of Health.
2So I asked the Department of Health for the data from its listening exercise with the public.
Did anyone write in asking for CHCs to be scrapped and suggesting something along the lines of what was proposed? Did anyone (apart from me) write in saying they wanted CHCs strengthened? What results were presented to the modernisation action team on patient empowerment to help them in their deliberations? No such information was available, I was told.
So maybe the notes of the modernisation action team itself might shed some light on how the proposals came about? Possibly, but the DoH told me the deliberations of the team were strictly confidential. So I spoke to a couple of people who had attended the relevant team meeting. Could they shed any light on all this? Neither could recollect any discussion about the possibility of abolishing CHCs and fully expected them to have a continuing role in the new arrangements.
My next line of enquiry was how the DoH had used responses to the NHS plan to inform their deliberations in the face of the widespread concern about CHCs.
Though there was to be no consultation on the NHS plan, the DoH website boldly encouraged readers to feed in comments to health secretary Alan Milburn himself. So, surely the many e-mails and letters that I know were sent will have been collected and analysed in order for the minister to see what patients and the public really felt about his plans?
At the very least, I thought, figures would be available on the number of standard letters which had been sent out to people like me, who had written in to suggest a rethink on the policy on CHCs. No such luck. Even these crude numbers were not available, I was told. But I did find a friendly member of the administration staff at Quarry House who was prepared to confide in me that the number had been 'very large - probably thousands'.
I had better luck in Wales, where the Welsh Assembly is allowed to do its own thing and had the radical idea of actually consulting patients, the public and voluntary groups about how they would like to be involved and empowered in the NHS. The results were unequivocal.
The most striking thing about the feedback from this consultation, according to the report by independent consultants, was the strong and consistent support for retaining and strengthening CHCs.
3The result has been that Welsh CHCs are being reformed and strengthened - and they are also being retained, in their slightly different forms, in Scotland and Northern Ireland.
So is there anything to suggest that the results of a consultation in England, if the minister were to allow it, would provide a different result and justify a completely different system in England?
Colleagues attending the annual conference of the Association of CHCs in England and Wales assured me not. But in the absence of any significant evidence, I decided to conduct my own research.
In August, I conducted a postal survey of 350 members of councils for voluntary service - umbrella organisations for local voluntary and community groups - asking their views about CHCs and other issues concerning local patient and public empowerment. The survey produced a good response of 142 - just over 40 per cent.
The results showed that 73 per cent of respondents thought that CHCs should be 'reformed and strengthened to play a pivotal role in the new arrangements', as opposed to being abolished and replaced with new bodies.
A further 3 per cent thought CHCs should be 'left as they are'.
Although a significant proportion of respondents (21 per cent) was in favour of abolishing CHCs and making a new start, half of these same respondents agreed with the majority view expressed that there was an ongoing need for a local NHS watchdog role, notwithstanding the new measures such as local authority overview and scrutiny committees and/or thought that independent advocacy should be provided by a new body equivalent to the CHC.
Almost three-quarters (74 per cent) of respondents felt the 'independent advocacy' service should be provided by CHCs or an 'equivalent' body.
These results, seen in the context of evidence from the consultation undertaken in Wales and the reaction that the government got from almost every quarter the first time it threatened to abolish CHCs, would seem to suggest that the latest proposals have failed to take on board the clear message that most people want to see something not dissimilar to CHCs at local level.
The government's discussion document, Patient and Public Involvement in Healthcare , proposes no organisation for patients and the public beyond individual trust level.
4It is not my intention, however, to discuss the government's latest proposals in detail here. The potential implications of the approach taken here are far more serious than the crude questions of what organisations or structures there should be.
Why has the DoH never undertaken the kind of research which I was able to do in a modest way through this survey? Why is there a refusal to consult formally on the proposals for England?
Why, if these proposals are genuinely intended to empower patients and the public and make the NHS more responsive to what they want, does so little account seem to have been taken of what people have been saying up and down the country since the first threat to abolish CHCs? And why, if there is a willingness to listen to what patients and the public think about the substantive issues, does the current discussion document not invite any feedback at all on the most contentious issue - the intention to do away with CHCs without even the compromise replacements for them that had been agreed during last year's debates? (Remember 'patients councils'? ) Perhaps the answers to some of these questions lie in the New Labour definition of what it means to 'empower', 'consult' and 'listen'. If my worst fears are correct, holding a listening exercise before you announce exactly what you are going to do provides you with all the justification you need to convince yourself that your decisions reflect the people's wishes. You no longer have to cite any analysis or evidence to support your assumptions. And least of all do you need to ask the people concerned any direct questions about the substantive issues.
Ministers sought to claim that the 'listening exercise' before the publication of the NHS plan took away the need to consult on the abolition of CHCs. Then the DoH received a great deal of feedback to suggest that its plans were opposed by the people they were meant to empower, but failed to keep any meaningful record that can be used to inform a review of the policy.
And then it launched a discussion document which, despite all that has gone before, starts with the premise that, whatever else, it must move as soon as possible to get rid of CHCs.
We can begin to imagine how much say the public might be allowed over changes to NHS services in this brave new world. A hospital closure would be justified by a massive 'listening exercise' in which the public would be asked whether they supported the idea that services should be 'modern and dependable' and a resounding majority would agree.
No further consultation would be deemed necessary, other than with the local authority's overview and scrutiny committee, which is a statutory requirement, as the closure would be intended to make services more modern and dependable.
The overview and scrutiny committee, which happens to be in a Labour-run local authority, would agree that, despite the huge number of representations opposing the proposal, closure was essential to meet the government's modernisation agenda. And there would be no awkward organisation like a CHC around to insist on a vigorous debate and unpick the rationale of the overall strategy.
The future of CHCs is far from the most pressing issue facing the NHS today. But the approach being taken by the government suggests that it is part of a more worrying sea-change in the attitude to empowering the public. l Key points lThe government's handling of the issue does not bode well for future consultation in the NHS.
lThe government's decision to abolish community health councils in England does not appear to be the result of public consultation.
A survey of councils for voluntary service in England suggests that most are in favour of strengthening and reforming CHCs.
1 Department of Health.
The NHS plan. The Stationery Office, 2000.
2 College of Health.
Shifting Gears - towards a 21st century NHS.
College of Health, 2000.
3 Scowcroft A.
Modernising Patient Advocacy and Support:
summary of consultation feedback. The Welsh Assembly, 2001.
4 Department of Health.
Patient and Public Involvement in Healthcare: a discussion document. DoH, 2001.
Peter Walsh is chief officer of Croydon community health council.